Circulating serum cell-free dna biomarkers and methods

ABSTRACT

Biomarkers and methods for identifying circulating serum-based cfDNA sequences. The cfDNA sequences (PDcRAs) can be used to differentiate patient&#39;s suffering from Parkinson&#39;s disease (PD) from non-PD patients.

BACKGROUND OF THE INVENTION 1. Field of the Invention

The present invention relates to identification and utility ofcirculating cell-free DNA in serum as diagnostic biomarkers inParkinson's disease to diagnose the disease and assist the clinicians todetermine the treatment options for a subject.

2. Brief Description of the Background Art

Parkinson's disease (PD), the second most common neurodegenerativedisease, is a movement disorder characterized by the demise ofdopaminergic neurons. Due to unknown etiology and lack of clinicalbiomarker the current treatment is only for symptomatic relief. L-dopatreatment in addition to other drug combinations alleviates the motorsymptoms but cannot reverse or halt the process of neuronal cell death.There are neither any objective tests nor any established biochemicalbiomarkers for the diagnosis of PD. Further, the heterogeneity, subtypesand the progression of the disease makes it even complex to developspecific therapeutic candidates. Thus it is imperative to diagnosedisease at the early stage to increase the efficacy of therapeuticagents as well as to employ new therapies that can be beneficial topatients.

The cell-free DNA (cfDNA) was first detected in blood plasma by Mandeland Metais in 1948 (1). It took many years before the application ofcfDNA as a tool for diagnostic purpose. Initial and arguably mostsuccessful application of cfDNA was in fetal DNA-based prenatial testingthat ranged from sex-determination to detect various genetically linkeddevelopmental and other diseases (2). This also points to the fact thatthe cfDNA found in blood has chimeric origin of diseased as well ashealthy cells. cfDNA is highly fragmented, double stranded DNA is mostly150 bp in length and found freely circulating in the blood. Mostfragments of cfDNA correspond to length of nucleosome units, the primarybuilding block of nuclear DNA. This suggests the cell death as majorsource of cfDNA in blood. This property of cfDNA is key to itsapplication as a diagnostic biomarker especially in diseases associatedwith cell death or apoptosis. The cfDNA amounts in patient samples coulddiffer and its function remains largely elusive after 70 years sinceinitial discovery. Since there are factors like sample collection, bloodcell lysis that can affect the cfDNA yield in plasma samples, serum canbe an alternative source for biomarker discovery.

SUMMARY OF THE INVENTION

It is an object of the present invention to identify serum cfDNAsequences relevant to patients suffering from Parkinson's disease. It isanother object of the present invention to provide methods fordetermining patients suffering from Parkinson's disease.

These objects and others are achieved by the present invention, whichprovides circulating cfDNA biomarkers that may be used singly, in pairsor in combination to determine patients suffering from Parkinson'sdisease.

DETAILED DESCRIPTION OF THE INVENTION

Unless defined otherwise, all technical and scientific terms used hereinhave the meaning commonly understood by a person skilled in the art towhich this invention belongs. The following references provide one ofskill with a general definition of many of the terms used in thisinvention: Singleton et al., Dictionary of Microbiology and MolecularBiology (2nd ed. 1994); The Cambridge Dictionary of Science andTechnology (Walker ed., 1988); The Glossary of Genetics, 5th Ed., R.Rieger et al. (eds.), Springer Verlag (1991); and Hale & Marham, TheHarper Collins Dictionary of Biology (1991). As used herein, thosefollowing terms have the meanings ascribed to them unless specifiedotherwise.

Methods Serum Samples Handling and Classification

All patients and controls participated in the Norwegian ParkWestproject, which are ongoing prospective population-based longitudinalcohort studies investigating the incidence, neurobiology and prognosisof PD. The Norwegian ParkWest study is a prospective longitudinalmulticenter cohort study of patients with incident Parkinson's disease(PD) from Western and Southern Norway. Between November 1st 2004 and31st of August 2006 it was endeavored to recruit all new cases ofParkinson Disease within the study area. Since the start of the study212 of 265 (80%) of these patients and their age-/sex-matched controlgroup have been followed. Further information about this project can befound at http://www.parkvestno.

All possible efforts were undertaken to establish an unselected andpopulation-representative cohort of patients with PD. Patients wereincluded if they had provided serum at study entry and fulfilleddiagnostic criteria for PD of the National Institute of NeurologicalDisorders and Stroke(http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_disease.htm)and UK Brain Bank(http://www.ncbi.nlm.nib.gov/projects/gap/cgi-bin/(GetPdf.cgi?id=phd000042)at latest follow-up. Patients with secondary parkinsonism at study entrywere excluded from this study. Control subjects were recruited frommultiple sources, including friends, spouses, and public organizationsfor elderly and were included in this study if they had provided serum.All patients and controls were Caucasian.

In this study of possible biomarkers for PD we utilized serum from 6patients and 3 controls which were selected at random.

Serum samples were collected at the same day as the clinicalexaminations and then stored frozen at −70 degrees Celsius untiltransported to the facilities in New York on dry ice.

EXAMPLE 1 Analyses of Differential Levels of Human cfDNA by NGS

cfDNA Isolation from Serum Samples and QC

After thawing on ice, nine (three control, six PD samples) serum sampleswere spun down for 5 mins at 3000×g to remove debris. The supernatantwas used to perform cfDNA isolation using E-Z Nucleic Acid (E.Z.N.A.®)circulating DNA Isolation Kit (Omega Bio-tek, GA). Before DNA Isolation,the samples were spiked with 0.1 pg/ul of spike-in control DNA (L34, Zeamays). The remaining part of the RNA isolation was performed followingmanufacturer's protocol. The isolated cfDNA was quantified on a Qubit 4Fluorometer (Thermo Scientific, MA) and quality of the cfDNA wasassessed by Alu assay and High sensitivity Bioanalyzer DNA assay(Agilent, CA). The cfDNA was then used for library preparation.

Library Prep, QC and Sequencing

The isolated cfDNA (15 ng) from nine patient serum samples weresubjected to sequencing library preparation using Accel-NGS® 2S Plus DNALibrary Kit (Swift Biosciences, MI) following manufacturer's protocol.The prepared libraries were quality checked and quantified using Qubit 4Fluorometer (Thermo Scientific, MA), KAPA Library Quantification Kits(KAPA Biosystems, MA) and Agilent 4200 TapeStation System (Agilent, CA).The spike-in control was recovered at consistent levels for all thesamples. The cfDNA libraries were sequenced using HiSeq 4000 Paired-End100 or PE150 Cycle lanes (Illumina, CA) at NYU School of Medicine'sGenome Technology Center(https://med.nyu.edu/research/scientific-cores-shared-resources/genome-teachnology-center).The fastq.gz files obtained from sequencing runs were imported intoPartek Flow (Partek, Mo.) for analysis.

NGS Data Analysis

Paired end sequencing data was imported into Partek Flow for dataanalysis. Quality control analysis demonstrated a read depth range of47,627,391-100,811,153, with a mean depth of 83,311,383. The data wasalso checked to ensure appropriate sequence quality with regards toaverage base score quality, the percent of missing bases, and GCcontent. Alignment of sequencing reads to the hg19 version of the humangenome assembly was performed using default parameters of the MEMalgorithm in the BWA aligner version 0.7.15 (3, 4). Post alignmentquality control demonstrated an average alignment rate of 98.74% (min:98.36%, max: 99.22%), primarily composed of alignments mapping to aunique location (mean: 94.65%, min: 93.00%, max: 95.94%). The coverageof the genome ranged from 88.02%-92.08% (mean: 91.15%), with an averagecoverage depth of 8.60 (min: 5.08, max: 10.26). The aligned reads werethen filtered to remove duplicate reads in the data set. DNA copy numberanalysis was performed independently for each sample utilizingControl-FREEC version 11.0, using default parameters and a window of 5kb (5). The resulting segment ratios of regions of copy number imbalancewere imported into Partek Genomics Suite version 6.6, and data wasfiltered to exclude identified regions of gain and loss found in controlsample. Recurrent regions of gain and loss were then identified todetermine regions conserved across all cases and those unique to eithermoderate or severe groups. These regions of copy number imbalance werethen annotated with regards to their proximity to gene content utilizingthe RefSeq.

Differentially Expressed Human cfDNA Sequences

The differentially expressed human cfDNA sequences in Parkinson'sdisease patients' serum samples from The Norwegian ParkWest study weredetermined employing NGS. Table 1 below illustrates the cfDNA sequenceswith statistically significant differential levels in PD patient serumsamples obtained by methods explained in [00010]. The identifiedchromosomes that were used for data analysis are known to those ofordinary skill herein from the human genome sequence (hg19—GenomeReference Consortium Human Build 37 (GRCh37)) found athttps://www.ncbi.nlm.nib.gov/assembly/GCF)_000001405.13/

TABLE 1 Average Fold Seq. Chromo- Seq. Seq. Relative change ID. someStart Stop Copy Number in levels 1 2 37960000 37965000 3.658 1.829 2 237965000 37970000 3.658 1.829 3 2 37970000 37975000 3.658 1.829 4 237975000 37980000 3.658 1.829 5 2 37980000 37985000 3.658 1.829 6 237985000 37990000 3.658 1.829 7 2 37990000 37995000 3.658 1.829 8 237995000 38000000 3.658 1.829 9 2 38000000 38005000 3.658 1.829 10 289070000 89075000 4.132 2.066 11 2 89075000 89080000 4.132 2.066 12 289080000 89085000 4.132 2.066 13 2 95470000 95475000 5.136 2.568 14 295475000 95480000 5.136 2.568 15 2 98125000 98130000 4.297 2.149 16 298130000 98135000 4.297 2.149 17 3 40245000 40250000 7.275 3.637 18 346160000 46165000 7.435 3.718 19 4 5315000 5320000 8.866 4.433 20 427695000 27700000 4.963 2.482 21 6 29685000 29690000 4.569 2.285 22 6162295000 162300000 8.784 4.392 23 6 170705000 170710000 7.853 3.927 248 144750000 144755000 4.551 2.275 25 8 7095000 7100000 1.282 0.641 26 87100000 7105000 1.325 0.663 27 8 7105000 7110000 1.325 0.663 28 87110000 7115000 1.325 0.663 29 8 7115000 7120000 1.325 0.663 30 87120000 7125000 1.325 0.663 31 8 7125000 7130000 1.325 0.663 32 87130000 7135000 1.325 0.663 33 8 7135000 7140000 1.325 0.663 34 87140000 7145000 1.325 0.663 35 8 7145000 7150000 1.325 0.663 36 87150000 7155000 1.325 0.663 37 8 7155000 7160000 1.325 0.663 38 87160000 7165000 1.325 0.663 39 8 7165000 7170000 1.325 0.663 40 87170000 7175000 1.325 0.663 41 8 7175000 7180000 1.325 0.663 42 87180000 7185000 1.325 0.663 43 8 7185000 7190000 1.325 0.663 44 87190000 7195000 1.325 0.663 45 8 7195000 7200000 1.325 0.663 46 969680000 69685000 4.481 2.240 47 9 69685000 69690000 4.481 2.240 48 940815000 40820000 1.116 0.558 49 9 40820000 40825000 1.116 0.558 50 940825000 40830000 1.116 0.558 51 9 40830000 40835000 1.116 0.558 52 10119940000 119945000 4.837 2.419 53 11 106580000 106585000 5.750 2.875 5411 119610000 119615000 4.945 2.473 55 12 38150000 38155000 2.653 1.32756 12 38155000 38160000 2.653 1.327 57 12 38160000 38165000 2.653 1.32758 12 38165000 38170000 2.653 1.327 59 12 38170000 38175000 2.653 1.32760 12 38175000 38180000 2.653 1.327 61 12 38180000 38185000 2.653 1.32762 12 38185000 38190000 2.653 1.327 63 12 38190000 38195000 2.653 1.32764 12 38195000 38200000 2.653 1.327 65 12 38200000 38205000 2.653 1.32766 12 38205000 38210000 2.653 1.327 67 12 38210000 38215000 2.653 1.32768 12 38215000 38220000 2.653 1.327 69 12 38220000 38225000 2.653 1.32770 12 38225000 38230000 2.653 1.327 71 12 38230000 38235000 2.653 1.32772 12 38235000 38240000 2.653 1.327 73 12 38240000 38245000 2.653 1.32774 13 53685000 53690000 3.635 1.817 75 14 34815000 34820000 6.120 3.06076 14 106780000 106785000 3.412 1.706 77 14 106785000 106790000 3.4121.706 78 14 106790000 106795000 3.412 1.706 79 14 106795000 1068000003.450 1.725 80 14 106800000 106805000 3.450 1.725 81 14 106805000106810000 3.450 1.725 82 15 84855000 84860000 3.840 1.920 83 15 8486000084865000 3.840 1.920 84 15 84865000 84870000 3.840 1.920 85 17 4153500041540000 5.425 2.712 86 17 43590000 43595000 4.612 2.306 87 17 3467000034675000 1.143 0.571 88 18 19790000 19795000 4.416 2.208 89 19 1988500019890000 3.685 1.842 90 19 52135000 52140000 0.216 0.108 91 19 5214000052145000 0.216 0.108 92 19 52145000 52150000 0.216 0.108 93 22 1723500017240000 4.942 2.471 94 22 24275000 24280000 0.925 0.463 95 22 2428000024285000 0.925 0.463 96 22 24285000 24290000 0.925 0.463 97 22 2429000024295000 1.083 0.542 98 22 24295000 24300000 1.083 0.542 99 22 2430000024305000 1.083 0.542 100 22 24305000 24310000 1.083 0.542 101 2224310000 24315000 1.083 0.542 102 22 24315000 24320000 1.083 0.542 10322 24320000 24325000 1.083 0.542 104 22 24325000 24330000 1.083 0.542105 22 24330000 24335000 1.077 0.538 Note: Copy number is the averagecopy number in PD serum samples assuming the copy number for controlsamples as 2.

EXAMPLE 2

Measurement of levels of a combination of many cfDNA sequences in serumfrom patients can assist or improve the accuracy in distinctlydifferentiating between a potential PD patient and a healthy individual.A serum sample is obtained from blood withdrawn from patients suspectedof PD. The serum is used for total cfDNA isolation and enrichment. ThisRNA would then be tested using NGS or qPCR to measure the levels of anytwo or more of the 105 cfDNA sequences mentioned in Example 1.Detectable levels of any two or more of the 105 cfDNA sequences confirmsthe patient has PD. If desired, other sample fluids may be utilized,including plasma, venous or arterial blood, or CSF samples withdrawn bylumbar puncture. Such plasma, blood or CSF samples are processed asabove. It will be understood that measurement of more than two cfDNAsequences in combination or a set of combinations used in a test matrixmay desirably increase the accuracy of PD diagnosis. Similarly,practitioners of ordinary skill herein will further appreciate thatshorter DNA sequences within any of the identified cfDNA sequences maydesirably be utilized instead of the entire cfDNA sequence. Theseshorter DNA sequences are preferably unique to the SEQ ID NO. in whichthey are found, and may have lengths on the order of about 1000 bp, 900bp, 800 bp, 700 bp, 600 bp, 500 bp, 400 bp, 300 bp, 200 bp, 100 bp, 50bp or 25 bp.

EXAMPLE 3

A microarray tray is provided containing labeled nucleotide sequencesthat are antisense to selected cfDNA SEQ ID NOS. among cfDNA SEQ ID NOS.1-105. The labeled antisense nucleotide sequences may be antisense toshorter DNA sequences found with the selected cfDNA SEQ ID NOS., whichshorter DNA sequences are preferably unique to the cfDNA sequencesencompassing them. Alternatively, the microarray tray may containlabeled antibodies that specifically bind selected cfDNA SEQ ID NOS.among cfDNA SEQ ID NOS. 1-105. The labeled antibodies may specificallybind shorter DNA sequences found with the selected cfDNA SEQ ID NOS.,which shorter DNA sequences are preferably unique to the cfDNA sequencesencompassing them. The term “antibody” includes both polyclonal andmonoclonal antibodies. The phrase “specifically (or selectively) binds”refers to a binding reaction between two molecules that is at least twotimes the background and more typically more than 10 to 100 timesbackground molecular associations under physiological conditions.Specific binding is determinative of the presence of the DNA or cfDNA,in a heterogeneous population cfDNAs. Thus, under designated immunoassayconditions, the specified antibodies bind to a particular DNA sequence,thereby identifying its presence as well as the presence of the cfDNAencompassing it. Specific binding antibodies may be characterized byhaving specific binding activity (K_(a)) of at least about 10⁵ M⁻¹, 10⁶M⁻¹ or greater, preferably 10⁷ M⁻¹ or greater, more preferably 10⁸ M⁻¹or greater, and most preferably 10⁹ M⁻¹ or greater. The binding affinityof an antibody can be readily determined by one of ordinary skill in theart, for example, by Scatchard analysis (Scatchard, Ann. NY Acad. Sci.51: 660-72, 1949). Methods of making antibodies are well known to thoseskilled in the art (Winter and Harris, Immunol. Today 14:243-246 (1993);Ward et al., Nature 341:544-546 (1989); Harlow and Lane, supra, 1988;Hilyard et al., Protein Engineering: A practical approach (IRL Press1992); Borrabeck, Antibody Engineering, 2d ed. (Oxford University Press1995); each of which is incorporated herein by reference).

EXAMPLE 4

Many neurodegenerative diseases are closely related to each other whenit comes to symptoms as well as pathological markers. The circulatingdiagnostic markers for one neurodegenerative disease can be useful fordiagnosis of other disease. A method to diagnose other neurodegenerativediseases like Dementia with Lewy body (DLB), Amyotrophic lateralsclerosis (ALS), Alzheimer's disease (AD), Multiple system atrophy(MSA), CorticoBasal Degeneration (CBD), Progressive Supranuclear Palsy(PSP) can also be developed using similar cfDNA sequences measurementsof candidates mentioned above. Disease specific kits can be developedsimilar to one mentioned in [0014] with various combinations of DNA orcfDNA sequences listed in [0012] and [0013].

EXAMPLE 5

The absence or presence of one or more combinations of DNA or cfDNAsequences in PD patient samples as compared to control samples can beused to develop disease specific kit as mentioned in [0014].

EXAMPLE 6

The function of the cfDNA sequences which may cross blood brain barrierdepending on the size of molecule is poorly understood but a diseasespecific sequence can be targeted for understanding PD etiology and totarget them for therapy.

EXAMPLE 7

Small nucleic acid molecules derived from cfDNA sequences mentioned in[0012] and [0013] will be designed to therapeutically intervene byspecifically targeting genes in PD brains to achieve complete or partialremedy.

1. A method for determining Parkinson's disease in a human patient,comprising the steps of: obtaining a sample from said human patient; anddetermining the differential level of DNA sequences within each of atleast three cfDNA sequences selected from the group consisting of SEQ IDNOS: 1-105 within said sample.
 2. The method of claim 1, wherein saidsample is serum, plasma or whole blood.
 3. The method according to claim2, wherein the differential level of said DNA sequences is determinedusing direct qRT-PCR in said sample.
 4. The method according to claim 1,wherein the differential level of said DNA sequences is determined usingqRT-PCR.
 5. The method according to claim 1, wherein the differentiallevel of said DNA sequences is determined using labeled antisensenucleotide sequences.
 6. The method according to claim 1, wherein thedifferential level of said DNA sequences is determined using microarrayprofiling.
 7. The method according to claim 1, wherein the differentiallevel of said DNA sequences is determined using high throughput NGSsequencing.
 8. The method according to claim 1, wherein the differentiallevel of said DNA sequences is determined using labeled antibodies. 9.The method according to claim 8, wherein the labeled antibodies aremonoclonal.
 10. A method for determining Parkinson's disease in a humanpatient, comprising the steps of: obtaining a sample from said humanpatient; and determining the differential level of DNA sequences withineach of at least two cfDNA sequences selected from the group consistingof SEQ ID NOS: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16,17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34,35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52,53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70,71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88,89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104 and105 within said sample.
 11. The method of claim 10, wherein said sampleis serum, plasma or whole blood.
 12. The method according to claim 11,wherein the differential level of said DNA sequences is determined usingdirect qRT-PCR in said sample.
 13. The method according to claim 10,wherein the differential level of said DNA sequences is determined usingqRT-PCR.
 14. The method according to claim 10, wherein the differentiallevel of said DNA sequences is determined using labeled antisensenucleotide sequences.
 15. The method according to claim 10, wherein thedifferential level of said DNA sequences is determined using microarrayprofiling.
 16. The method according to claim 10, wherein thedifferential level of said DNA sequences is determined using highthroughput NGS sequencing.
 17. The method according to claim 10, whereinthe differential level of said DNA sequences is determined using labeledantibodies.
 18. The method according to claim 17, wherein the labeledantibodies are monoclonal.
 19. A method for determining Parkinson'sdisease in a human patient, comprising the steps of: obtaining a samplefrom said human patient; and determining the differential level of DNAsequences within each of at least two cfDNA sequences selected from thegroup consisting of SEQ ID NOS: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 46, 47, 52, 53, 54, 55,56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73,74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 88, 89, and 93within said sample.
 20. The method of claim 19, wherein said sample isserum, plasma or whole blood.
 21. The method according to claim 20,wherein the differential level of said DNA sequences is determined usingdirect qRT-PCR in said sample.
 22. The method according to claim 19,wherein the differential level of said DNA sequences is determined usingqRT-PCR.
 23. The method according to claim 19, wherein the differentiallevel of said DNA sequences is determined using labeled antisensenucleotide sequences.
 24. The method according to claim 19, wherein thedifferential level of said DNA sequences is determined using microarrayprofiling.
 25. The method according to claim 19, wherein thedifferential level of said DNA sequences is determined using highthroughput NGS sequencing.
 26. The method according to claim 19, whereinthe differential level of said cfDNA sequences is determined usinglabeled antibodies.
 27. The method according to claim 26, wherein thelabeled antibodies are monoclonal.
 28. A method for determiningParkinson's disease in a human patient, comprising the steps of:obtaining a sample from said human patient; and determining thedifferential level of DNA sequences within each of at least two cfDNAsequences selected from the group consisting of SEQ ID NOS: 25, 26, 27,28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45,48, 49, 50, 51, 87, 90, 91, 92, 94, 95, 96, 97, 98, 99, 100, 101, 102,103, 104 and 105 within said sample.
 29. The method of claim 28, whereinsaid sample is serum, plasma or whole blood.
 30. The method according toclaim 29, wherein the differential level of said DNA sequences isdetermined using direct qRT-PCR in said sample.
 31. The method accordingto claim 28, wherein the differential level of said DNA sequences isdetermined using qRT-PCR.
 32. The method according to claim 28, whereinthe differential level of said DNA sequences is determined using labeledantisense nucleotide sequences.
 33. The method according to claim 28,wherein the differential level of said DNA sequences is determined usingmicroarray profiling.
 34. The method according to claim 28, wherein thedifferential level of said DNA sequences is determined using highthroughput NGS sequencing.
 35. The method according to claim 28, whereinthe differential level of said DNA sequences is determined using labeledantibodies.
 36. The method according to claim 35, wherein the labeledantibodies are monoclonal.
 37. A method for determining Parkinson'sdisease in a human patient, comprising the steps of: obtaining a samplefrom said human patient; and determining the differential level of a DNAsequences within at least one cfDNA sequence selected from the groupconsisting of SEQ ID NOS: 1-105 within said sample.
 38. The method ofclaim 37, wherein said sample is serum, plasma or whole blood.
 39. Themethod according to claim 38, wherein the differential level of said DNAsequences is determined using direct qRT-PCR in said sample.
 40. Themethod according to claim 37, wherein the differential level of said DNAsequence is determined using qRT-PCR.
 41. The method according to claim37, wherein the differential level of said DNA sequence is determinedusing a labeled antisense nucleotide sequence.
 42. The method accordingto claim 37, wherein the differential level of said DNA sequence isdetermined using microarray profiling.
 43. The method according to claim37, wherein the differential level of said DNA sequence is determinedusing high throughput NGS sequencing.
 44. The method according to claim37, wherein the differential level of said DNA sequence is determinedusing a labeled antibody.
 45. The method according to claim 44, whereinthe labeled antibody is monoclonal.